On this episode of Interventional Mindset, Preeya K. Gupta, MD, is joined by Mitchell A. Jackson, MD, and Melissa Bollinger, OD, to discuss advances in presbyopia drops and clinical insights into QLOSI (pilocarpine 0.4%, Orasis Pharmaceuticals).
Dr. Jackson is a refractive, cataract, and anterior segment surgeon and the Founder and Medical Director of Jacksoneye in Lake Villa, Illinois, and a clinical assistant at the University of Chicago Hospitals.
Dr. Bollinger is an optometrist at Jacksoneye with a focus on managing dry eye and ophthalmic surgery patients.
Overview of QLOSI
To start, QLOSI was approved by the FDA in October 2023 and launched in the US market in April 2025. The FDA approval was based on two multicenter, randomized, double-masked phase 3 clinical trials (NEAR-1 [NCT04599933] and NEAR-2 [NCT04599972]) that included 613 patients.1
Notably, both trials met their primary and key secondary endpoints on Day 8, reaching a statistically significant 3-line or more gain in distance-corrected near visual acuity and no loss of 1-line or more in distance visual acuity.2
Having been involved in the clinical trials for both VUITY (pilocarpine hydrochloride ophthalmic solution 1.25%, Allergan, an AbbVie company) and QLOSI, Drs. Jackson and Bollinger explained that they have observed key differences in patient responses to both drops. Namely, that patients appreciate the flexible dosing schedule, and fewer patients have reported headaches with QLOSI.
Features of QLOSI
While QLOSI and VUITY are both cholinergic receptor agonists, QLOSI features a preservative-free formulation of low-dose (0.4%) atropine. This unique EyeQ Formulation enables a “pinhole effect” that enhances depth of focus while minimizing the risk of diffraction by maintaining an optimal pupil size of 2 to 3mm.1
Additional features of the EyeQ Formulation include:1
- A near-neutral pH solution to increase its bioavailability
- Dual lubricating agents for ocular comfort, including:
- Hyaluronic acid: Provides anti-inflammatory, antioxidant, and anti-toxic effects for ocular surface comfort
- Hydroxypropyl methylcellulose: Relieves dryness and irritation caused by reduced tear flow
Moreover, as QLOSI can last up to 8 hours following application and can be repeated 2 to 3 hours after the first drops to extend the treatment effect, the drop allows for customizable dosing to address patients’ needs, whether it is for work or hobbies.
In terms of adverse reactions, the most common treatment-related occurrences were instillation site pain and headaches, which occurred in 5.8% and 6.8% of patients in clinical trials, respectively, and were reported to be mild, transient, and self-resolving.2
Optimal patient selection for QLOSI
Dr. Bollinger noted that presbyopia is one of the largest markets in eyecare, and it brings in a new group of patients who have good distance vision but need drugstore reading glasses—creating an opportunity to introduce this new therapy to them when they are in the office. She added that the patients who benefit the most from QLOSI are those with low refractive error (i.e., low hyperopes and myopes).
She has also found that post-refractive patients are often the most excited and interested in trying QLOSI because they don’t want to wear glasses for near activities. This can include pseudophakic patients with monovision intraocular lenses (IOLs) and those who have undergone myopic LASIK, who may benefit from improved near vision that they can tailor to their specific needs.
However, before prescribing QLOSI, it is critical that patients undergo a comprehensive ocular examination with a dilated fundus exam and even macula OCT (if available) to ensure that they don’t have a history of retinal problems and are free of existing retinal holes or tears. Further, it is important to discuss with patients that there is a low risk of retinal detachment associated with using miotics.3
Patient education on Qlosi
Drs. Bollinger and Jackson noted that there is an adaptation period with QLOSI, and when VUITY was released, most doctors weren’t sufficiently educated on this phenomenon and consequently allowed patients to discontinue the medication before they had fully adjusted.
However, patient education on this side effect has improved, allowing both doctors and patients to anticipate it and know that it will likely subside after at least 2 weeks of use.
Dr. Jackson added that it is important to prepare patients by specifically mentioning potential side effects, such as headache, brow ache, and redness, and even explaining that their pupils will constrict, as some patients may think it’s an unintended side effect of the medication.
To learn more tips for discussing QLOSI with patients, watch the full interview!
What’s coming in the future for presbyopia
Recently, VIZZ (aceclidine ophthalmic solution 1.44%, LENZ Therapeutics) received FDA approval, highlighting the continuous advancements in presbyopia drops.
Table 1: List of presbyopia drops approved and in the pipeline.4,5
Conclusion
QLOSI represents a meaningful advancement in presbyopia management, offering patients a flexible, preservative-free treatment with fewer reported side effects compared to earlier treatments like VUITY.
With proper patient selection, education, and awareness of potential risks, QLOSI provides clinicians with an effective new tool and marks an important step forward as additional therapeutic options continue to emerge.
